As a father of two young boys, the statistics on brain injuries caused or acquired by accidents or other traumas are truly the stuff of nightmares.  According to Brain Injury Australia:

  • Over 600,000 Australians have an acquired brain injury.
  • Three out of every four are aged under 65.
  • As many as two out of every three acquired their brain injury before they turned 25.
  • Three out of every four people with acquired brain injury are men.
  • Over 22,000 Australians were hospitalised as a result of a traumatic brain injury in 2004-2005.
  • Most of those injuries – over two in every five – were caused by a fall, nearly one in three was due to a motor vehicle accident and one in six was caused by an assault.

“Acquired brain injuries” (as they are called) can have devastating effects, including:

  • on-going medical difficulties;
  • changes in physical and sensory abilities;
  • changes in the ability to think and learn (cognition);
  • changes in behaviour and personality (psychological); and
  • so-called “cognitive communication” disorders.

Common cognitive communications disorders

Often, people with an acquired brain injury retain their basic language functions (e.g. their ability to understand and speak in sentences).  It’s rare for people with acquired brain injuries to have language-specific problems like aphasia.  But, because brain injuries can cause problems with “cognitive” brain functions like attention, memory, organisation, information processing, problem solving, self-control, and executive functions, people who have suffered brain injuries can have major problems communicating with others.

Common cognitive communication problems include difficulties:

  • listening to others;
  • conversing with others (e.g. staying on topic, not interrupting or talking too much); and
  • interacting with others appropriately (e.g. not swearing or talking about inappropriate things at work).

These problems are often long-term, and can have a major effect on the quality of life of people directly affected by brain injuries, and their families.

7 evidence-based rehabilitation principles

Over the years, various treatments have been recommended to help people with communication problems caused by brain injury.  But, for front-line speech pathologists with busy case loads, it’s difficult to stay up-to-date or even find the time to find and sift through the latest evidence to identify key principles of best practice.

Fortunately, we now have some expert guidance.

An international group of specialist researchers known as INCOG has published recommendations for management of cognitive communication problems. The group, including leading cognitive communication experts Professors Leanne Togher and Lyn Turkstra reviewed more than 600 peer-reviewed studies.  From this review, the researchers distilled 7 evidence-based principles to help assess and treat people with cognitive communication problems caused by acquired brain injuries.

Paraphrased into Plain English, the principles are as follows:

1. A person’s communication skills and competence may vary depending on who they are talking to (e.g. family members, the boss, a health professional, or a stranger in a shop), the situation (e.g. one-to-one or with lots of people, relaxed or under time pressure) and their emotional state (e.g. how tired they are).

2. People with cognitive communication problems should be treated by speech pathologists.  This seems obvious. But, because people with acquired brain injuries often don’t present with obvious language problems, they have not always been referred to speech pathologists trained in more subtle social and cognitive communication problems.

3. To treat a person with cognitive communication issues properly, speech pathologists need to know how the person communicated before their injury and how they need to communicate in their culture and “real lives”. For example, a Linguistics Professor has different communication needs to a gardener who prefers to work alone.  A person with 15 years of higher education communicates differently to someone who left school at the age of 14 and started their own business.  Some people say less and speak more slowly than others.  Some people grew up in families or communities that swear or shout at each other a lot, and use a lot of colourful slang.  Some people speak multiple languages, with different degrees of competence.  Some people are born chatterboxes.  Others are more introverted.  In some cultures, participating in large ceremonies is more important than talking one-to-one.  Some people prefer to communicate non-verbally wherever possible.  Ignoring these factors – particularly how the person communicated before their injury – makes no sense when the goal is to maximise someone’s participation in their real world.

4. People with cognitive communication problems should practice their communication skills in real world situations, e.g. at work and at home.  People with cognitive communication problems often have problems transferring skills from one place to another.  It doesn’t make sense to train people in a clinic, if they are not going to use their training out in the real world.  This means people and their families need to practice skills in the context they will actually need to use them.

5.  Rehabilitation should include education and training of “communication partners”.  By “communication partners”, the researchers mean the people who communicate the most with the person with cognitive communication problems.  Often, this means family members, partners and/or best friends.  But it can also include employers, work mates or anyone who will be communicating a lot with someone with cognitive communication problems.

6. Speech pathologists, occupational therapists and other rehabilitation professionals should ensure that people with severe communication problems related to brain injuries are trained and have access to alternative and augmentative communication aids to maximise their participation in activities.

7. People with social communication problems and their families should choose their own rehabilitation goals – the things that matter most to them – rather than being prescribed a program of what professionals think matters the most.  Progress should be measured by whether the treatment increases the person’s meaningful participation in every day social life – i.e. whether it makes a real world difference and increases the person’s quality of life.  Group treatment is recommended for people with social communication problems, as the best quality evidence supports group-based therapy.

Bottom Line

My key takeaway from the INCOG Recommendations is that people with cognitive communication problems caused by acquired brain injuries should receive evidence-based therapies:

  • delivered by appropriately-trained speech pathologists and other health professionals to both the person and his or her communication partners; and
  • tailored to:
    • who they are (including before their injury); and
    • what’s getting in the way of them communicating appropriately and effectively with the people they need to communicate with to participate fully in their preferred activities out in their real world.

Source: Togher, L., Wiseman-Hakes, C., Douglas, J., Stergiou-Kita, M., Ponsford, J., Teasell, R., Bayey, M., & Turkstra, L. (on behalf of the INCOG Expert Panel). 2014. INCOG Recommendations for Management of Cognition Following Traumatic Brain Injury, Part IV: Cognitive Communication. Journal of Head Trauma Rehabilitation, 29(4), 353-368.


Banter Speech & Language Banter Speech & Language
Banter Speech & Language is an independent firm of speech pathologists for adults and children. We help clients in our local area, including Concord, Rhodes, Strathfield and all other suburbs of Sydney’s Inner West.

Banter Speech & Language is owned and managed by David Kinnane, a Hanen- and LSVT LOUD-certified speech-language pathologist with post-graduate training in the Spalding Method for literacy, the Lidcombe and Camperdown Programs for stuttering, and Voicecraft for voice disorders. David is also a Certified PESL Instructor for accent modification.

David holds a Master of Speech Language Pathology from the University of Sydney, where he was a Dean’s Scholar. David is a Practising Member of Speech Pathology Australia and a Certified Practising Speech Pathologist (CPSP).

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